"That is happiness; to be disolved into something complete and great. When it comes to one, it comes as naturally as sleep." - Willa Cather

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Monday, 1 July 2013

Western States miracles through the eyes of a physician

At 10:30 AM, 29 hours into the Western States Endurace Run this morning, a finishing runner's quote is announced over the loud speakers: "The only help I ever got from a physician at Western States was from one who paced me". Awkward laughter and looks disperse around the medical tent.

Minutes later, a runner who is unable to speak and nearly completely unresponsive is brought by ambulance from the mile 89 checkpoint to the finish. Shortly after his arrival, he begins to have seizures. In a large part due to previous research at Western States, we know what the problem is immediately (do you??).

Now if you think you know what the problem is, what is the treatment? (think fast, we could very easily lose him). If you choose the wrong one, he'll get worse.

I'll tell you. But I'd like to know if you knew. When the body is under extreme physical stress, it retains urine (I think of it as an evolutionary mechanism to stay hydrated when there is not going to be access to water) and when there IS access to fluids and we drink them (even WITH salt tabs) 100 mile runners in races with extreme temperatures are at high risk for hyponatremia (low sodium). (think Susitna and Western States, for example).

The treatment is a bolus (100mL) of IV fluids with more sodium than is found in the blood (3% saline). When the runner received this, he stopped seizing and improved rapidly. Had he been sent to a local hospital, they most likely would have treated him for dehydration with regular isotonic saline (or even hypotonic) and could have sent him into a coma or killed him.

The medical team at Western States seems to have a bad reputation among the runners, so it was an interesting experience being on the "other side"

After all, technically my training is in medicine and not running. Western States started medical checkpoints because it was modelled after the 100 mile Tevas horse ride on the same trail- which gave Gordy the idea to run the route for the first time - and vets had to check the horses so why shouldn't humans get checked, too?

Gordy and me at packet pick-up

Well, after years of pulling racers from Western States due to a certain amount of weight change (or a certain blood pressure), it has been shown though research at the race that weight doesn't correlate well with blood levels of electrolytes or race outcomes. It turns out runners are a lot better off following their instinct (Okay, honestly, I had never liked the idea of pulling runners at WS, so I'm glad there is research to back this up). Trouble happens when runners are mistakenly encouraged to drink. Runners aren't held anymore or pulled. The medical team is now there to give advice and help when runners get into trouble. And of course, respond in an emergency.

And as I was stationed in the extreme heat at mile 39 and then the finish line, I witnessed what seemed to be something superhuman and even magical.

There were top runners who ran these 100 miles in over 100F in the unthinkable times of just over 15 hours. I could barely walk out into the sun to get runners' weights. And I got to be in the mindframe of that person who always asks me "how on earth do you run so long/so fast?", etc. Timothy Olson and Rob Krar achieved an absolutely astonishing feat yesterday. Honestly, did we know as humans and scientists that a time this fast in these temperatures was within the realm of possibility? What are the limits and are there consequences? (one of this year's research studies looks at the affects of ultra running on the heart, both immediate and long-term).

Rob Krar - 2nd in 15.22:05, Timothy Olson 1st in 15:17:27

These two men are genuine, kind, caring and have achieved something I find incomprehensible. I would love to know their secrets. It is not merely a question of genetics, but advancements in training and knowledge, not to mention others to learn from and follow.

Even more incredible, perhaps, is Pam Smith's win. She had a pace card shooting for 18:30 which she made before she knew it would be so hot. She stuck to it basically all the way and finished in 18:37 and took 9th overall, even outrunning Yassine Diboun and Karl Melzer. Last year she ran in around 29 hours, suffered from hypothermia and was held for 3 hours at an aid station due to weight gain (no more holds, thank goodness, as I said). As far as I know she didn't make it on any female top 10 lists, let alone for the men. She is just a woman from Oregon who lives in a town without trails and trains with men who love to run marathons on roads. And she works as a pathologist. How she did it, I do not know and she was completely calm and collected, even unfatigued afterwards. But one thing is certain, she had an extremely methodical training and race plan, sticks to it and believes in it 100% (my love and admiration go out to you Pam :0)).

Honestly over the last 48 hours, I have bared witness to miracles of knowledge, generosity, love and strength. As I said good-bye to Marty (research director) and thought about what I had experienced, I started to cry (a little :0)) - not tears of sadness or fatigue from sleeping just a couple hours in my car, but tears of joy, incredulous that I was allowed to be part of this. This life is amazing. Humans- working together, pushing each other, helping, inspiring each other. This is uncharted territory - athletically, medically - and not least of all, in terms of the love, support and effort that pacers, crews and volunteers provided to their athletes. I was there to see it and feel it. As I said this morning to Ve Loyce, the crazy, wonderful (painful!) race massage therapist: I am a sceptic in every way, but I believe in magic.

Thanks for your help at the finish. Amy looked pretty pale coming into the finish and I was worried about her. :) It was great to meet you briefly. Like Danni, I too am grateful for medical professionals willing to volunteer time for these events. I'm guessing the complaints were mostly centered around frustrated athletes who were being held at aid stations?

Also, your comments about extreme temperatures and hydration intrigued me. I always thought hyponatremia was mainly a concern in extreme heat, but you're saying extreme cold is an issue, too? In the 2011 Susitna 100, we experienced temperatures down to -20 with close to -50 windchills. It was definitely the most extreme cold I've had long-term exposure to. About 36 hours into the race, I started to feel really out of sorts — dizzy, confused, etc. — but it was also dropping into the -20s and dark again, so I associated these weird feelings with fatigue and also fear. Maybe an hour or two into this weirdness, I started peeing very frequently. As in, I would need to stop every 3-5 minutes, and not just a little bit of urine, but quite a lot. In the snow, the color looked to be light yellow to almost colorless later in this episode I was having. I never recorded how long it lasted, but it my memory it was probably 10 to 15 stops. Afterward, I felt quite a bit better mentally. It was a weird experience, and the only time anything like that ever happened to me. At the time I thought I was just retaining water. But maybe it was more dangerous than I knew?

I'm planning to race the Iditarod 350 in February; if you have any time in the next few months, I'd really appreciate a chance to chat with you some more about this. As you said, regular medical professionals don't always understand the context. But some insight in how to deal with this in the future would be much appreciated.

Jill, Great question! From research at Susitna and WS, it looks like hyponatremia occurs at the warmest and coldest temps in endurance events. What you experienced at Susitna was likely hyponatremia and, as you probably figured out, all the peeing was your body correcting it on it's own. My guess is you started correcting on your own because you slowed down because you weren't feeling well and just resting should start the process of raising the sodium again. How to avoid it is the million dollar question and it this point it seems like the best thing to do with headaches, nausea or confusion in these events is to slow down or stop and eat something salty. It is important you eat it and not swallow a pill because there is an important tongue signal from eating that will stop the urine retention. Happy to discuss this anytime over email or in person (if you pay for my fight ;0). Love your area of the world. Thanks for supporting Amy! She did awesome!!!

Hi I enjoy following your posts here - and similarly, your's too Jill. I was following the West Highland Way ( Scottish ) endurance ( 96 mile) race held recently and found an interesting medical lecture by the Doc in charge of their medical team.Might be of interest - link here http://www.westhighlandwayrace.org/downloads/Dr%20Chris%20Ellis%20-%202013.pdf

Tracy- Thanks for the kind words. It was great to meet you at WS. Thank you for being part of the med team. While what I went through wasn't so fun last year, I know a lot of the changes they made this year were in part due to what happened to me last year, so in the end it will benefit runners and benefit the race.

And to "Fat Bastard" - I am board certified in hematology; my specialty in pathology is blood diseases.

Thank you LTF. I went right away to the link and read the slides. Great info - those data are really similar to Western States' but actually less dramatic. I really appreciate that and asked Marty Hoffman if he was aware of the WHW data and he was. So at least all of the biggest researchers in the field know each other. I really appreciate that you sent that.

Hello from Rude Skov

Photo by Stine Sophie Winckel

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My name is Tracy. I am a physician scientist from the USA, living with my husband and two young boys in Denmark. I work as a post-doc fellow at Næstved Hospital. I have a scientific interest in vision loss, vision loss during exercise, exercise, running during pregnancy, MAF training as well as nutrition and health for athletes. I also have a love for music, physics, statistics, cycling, yoga, cross-country skiing, bla bla bal.

I was a member of Team USA at the IAU World Championships in Ultra Trail Running in 2013 in Wales. I am now training to run with Team Denmark at the IAU World Championships in Annency, France in May 2015.